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COOL Spine Course

Advanced Orthopaedics Course: 22-25 April 2014

AIC-CURE International Children’s Hospital, Kijabe, Kenya

COURSE REPORT

© Photo by G Le

COOL Spine Course, April 2014

Contents

Executive Summary ............................................................................................................................. 4

Background ......................................................................................................................................... 4

Objectives ........................................................................................................................................... 5

Faculty ................................................................................................................................................. 5

Participants ......................................................................................................................................... 6

Teaching .............................................................................................................................................. 7

Assessment ......................................................................................................................................... 7

Evaluation ........................................................................................................................................... 8

Future planning ................................................................................................................................... 9

Acknowledgements ........................................................................................................................... 10

APPENDIX 1: Comments from Participants ....................................................................................... 11

APPENDIX 2: Teaching Timetable ..................................................................................................... 12

APPENDIX 3: ...................................................................................................................................... 14

COSECSA Oxford Orthopaedic Link (COOL) ....................................................................................... 14

AIC-CURE International Children’s Hospital of Kenya ....................................................................... 14


Executive Summary

In April 2014 AIC-CURE International Children’s Hospital Kijabe, Kenya, hosted a pioneering three-

day spine course for surgical trainees from East and Central Africa. Held in the Rift Valley in Kenya,

this course was the first spine course for trainees in the 10 constituent countries of the regional

College of Surgeons of East, Central and Southern Africa (COSECSA). The course was led by Dr Joseph

Theuri, Medical Director at AIC-CURE Hospital Kenya, where there is a growing spinal department,

and Professor Chris Lavy, from the spinal unit at the Nuffield Orthopaedic Centre, Oxford, UK. 10

faculty members and 35 surgical trainees from around COSECSA attended the course. This course

was the second of a series of three COSECSA Oxford Orthopaedic Link (COOL) short courses aimed at

strengthening postgraduate orthopaedic training in the region. This introductory course provided an

overview and foundation of principles and approaches in spine surgery and generated interest in a

specialty where most of the delegates had limited prior experience. Feedback from participants was

very positive and there is strong interest in repeating this course elsewhere in the region.

Background

Spine surgery is an emerging sub-specialty in the region and practised in very few places. Amongst

the leading causes of spinal cord injuries (SCI) is trauma, many due to road traffic accidents and falls.

Spine damage as a result of tuberculosis and other infections is also common. There is, however,

very little data on the burden of SCI in the region and there are many challenges in managing these

conditions, such as poor pre-hospital care, delayed presentation, few ambulance services, limited

radiology, a critical shortage of human resources and a lack of dedicated acute spine injuries units.



Objectives

The course aim was to develop participants’ understanding of concepts of treatment and

management of spine conditions requiring surgery.

1. To provide an overview of spine conditions requiring surgery

2. To demonstrate the classic approaches to the spine in all the regions

3. To outline how common conditions are treated, including indications, operative technique

and complications

4. To demonstrate use of spinal instruments

Faculty

The faculty team was led by Dr Joseph Theuri and Professor Chris Lavy and drew on expertise from

the UK and around the region:

Mr. Gavin Bowden, Nuffield Orthopaedic Centre, Oxford, UK Prof. Alex Buteera, Rwanda Military Hospital / King Faisal Hospital, Kigali, Rwanda Prof. Chris Lavy, Nuffield Orthopaedic Centre, Oxford, UK Dr Anthony Maina, Kijabe Hospital, Kenya Dr Valentine Mandizvidza, Parirenyatwa Group of Hospitals, Harare, Zimbabwe Prof. Paul Marks, Harrogate General Hospital, UK Dr. Tim Mead, Michigan, USA (former Medical Director, AIC-CURE Hospital, Kijabe, Kenya) Prof. Nyengo Mkandawire, Queen Elizabeth Central Hospital, Blantyre, Malawi Dr Elijah Muteti, Moi Teaching and Referral Hospital, Eldoret Kenya Dr Joseph Theuri, Medical Director, AIC-CURE Hospital, Kijabe, Kenya

© Photos by John McLaughlin


Participants

The course was attended by 35 surgeons and postgraduate senior surgical trainees from 8 of the

COSECSA countries.

Dr Ephrem Gebrehana Addis Ababa University, Black Lion Hospital Dr Geletaw Tessema Addis Ababa University, Black Lion Hospital Dr Worku Belay Addis Ababa University, Black Lion Hospital Dr Mamo Deksisa Addis Ababa University, Black Lion Hospital Dr Nesredin Yusuf Dire Hospital, Jijiga, Ethiopia Dr Getnet Asnake Addis Ababa University, Black Lion Hospital Dr Geoffrey Chege AIC-CURE Hospital, Kijabe, Kenya Dr Robert Cheruiyot Moi Teaching Referral Hospital, Kenya Dr Caroline Gatoba University of Nairobi Dr James Kinyua AIC-CURE Hospital, Kijabe, Kenya Dr Paul Mang'oli AIC-CURE Hospital, Kijabe, Kenya Dr Petrus Marakalala Moi Teaching Referral Hospital, Kenya Dr Namumguba Mbute Moi Teaching Referral Hospital, Kenya Dr Levis Nguku AIC-CURE Hospital, Kijabe, Kenya Dr Philemon Nyambati AIC-CURE Hospital, Kijabe, Kenya Dr Victor Oteki Kisii Level 5 Hospital, Kenya Dr Peris N. Waithiru University of Nairobi Dr Kumbukani Manda Kamuzu Central Hospital, Malawi Dr Boston Munthali Kamuzu Central Hospital, Malawi Dr Nohakhelha Nyamulani Queen Elizabeth Central Hospital, Malawi Dr Albert Nzayisenga King Faisal Hospital, Rwanda Dr Bryson Mcharo Muhimbili Orthopaedic Institute, Tanzania



Dr Felix Mrita Muhimbili Orthopaedic Institute, Tanzania Dr Anthony Pallangyo Kilimanjaro Christian Medical Centre, Tanzania Dr Pamela T. K. Samoyo Kilimanjaro Christian Medical Centre, Tanzania Dr Justin Onen Cure Hospital, Mbale, Uganda Dr Nachor K. Bunda University Teaching Hospital, Lusaka, Zambia Dr Penelope K. Machona University Teaching Hospital, Lusaka, Zambia Dr Godfrey Phiri University Teaching Hospital, Lusaka, Zambia Dr Jonathan Sitali University Teaching Hospital, Lusaka, Zambia Dr Akimu C. Mageza Parirenyatwa Hospital, Zimbabwe Dr Raphael Makota Mpilo Hospital, Bulawayo, Zimbabwe Dr Munyaradzi Ndekwere Harare Central Hospital, Zimbabwe Dr Brian Paketh Parirenyatwa Group of Hospitals, Zimbabwe Dr Richard Thapelo Moi Teaching Referral Hospital, Kenya

Delegates’ previous experience of spine surgery

Attended spine teaching 48%

Assisted with spine operations 88%

Performed spine operations 18%

Teaching

This introductory spine course covered anatomy, imaging, surgical approaches, degenerative

changes, trauma, and deformity through a series of interactive lectures, case studies, discussions

and skills sessions. There was a practical session on pedicle screws using sawbones, pedicle screw

sets and drills. (See Appendix 2 for teaching schedule.)

Assessment At the start and end of the course participants completed a multiple choice questionnaire written by

the course faculty to assess baseline and increase in knowledge of spine conditions and treatment.

Pre-course

score Pre-course percentage

Post-course score

Post-course percentage

Percentage change

MAX 35 81% 38 88% 30%

MIN 18 42% 21 49% -7%

MEAN 26 61% 31 73% 12%

MEDIAN 26 60% 32 74% 12%

Most improved: Dr Ephrem Gebrehana, Black Lion Hospital, Ethiopia (30% percentage change)

Highest post-score: Dr Geoffrey Chege, AIC-CURE Hospital Kijabe, Kenya (88%)


Evaluation

All participants and faculty were invited to complete a course evaluation on the final day.

Average scores from 1-10 (1= poor; 10 = excellent)

Teaching Sessions 9

Case discussions 9

Opportunities for professional networking 9

The course overall 9

Did you enjoy the course? Yes = 97%

Would you recommend the course to a colleague? Yes = 100%

Would you be interested in attending a follow-up spine course? Yes = 100%

What did you enjoy about this course?

Objective, informative, helps to improve my patient management ++++++++++

Interaction with multiple surgeons ++++

Expert and knowledgeable teaching ++++

Eye-opener ++++

Other: lecturers bringing their cases; evidence-based; educative and stimulating



What was the best part of the course?

Comprehensive, in-depth introductory course +++++

Pedicle screws, step by step +++++

Interesting and dedicated lecturers, friendly delivery, diverse experience of faculty ++

Spine surgery is possible despite limited resources +

Well-organised +++

Other: opened up my mind; networking; value of apprenticeship; open discussion; correlating clinical presentation, radiological findings and management

What have you learned/gained that will benefit your future practice?

Understanding various approaches and techniques ++++

Consultation with colleagues improves outcomes

Diagnosis and management plans, improved decision-making +++

New interest in spine surgery +

Confidence in spine surgery ++

Eye opener. I will try to start a spine unit in my country.

Other: Better interpretation of radiographic investigations; approaching trauma patients; some tricks from the masters; demystified cervical fixation; refreshed anatomy; evaluation of MRIs; management of TB spine

How could this course be improved?

More practicals (inc live practicals, operative videos, equipment) ++++++++++++++++++

Case discussions every day/evenings – more of a problem-based approach +++

Cadavers ++++++++

Continue! +++

Pre-course reading material +

More on: spinal deformity, neurological examination, rehab for spinal patients, pedicle screws under fluoroscopy

Other: shorter presentations; visual aids; more eye-contact during teaching; Encourage spine surgeons to publish so that local data can be cited

Further comments

Encourage more spine training (fellowships, training hospitals) +++

Lovely course – continue running this course +++++

Overall very helpful +++++

Great organisation ++

Microphone +

Record teaching sessions to assist with future training

Faculty very nice and easy to interact with ++

Topics well prepared and presented, inspiring

Course dinner was awesome++

Wrist/hand course in the future

Future planning It is hoped that further spine training courses may be run again in the region as, encouragingly, all

respondents would recommend this course to their colleagues, and all would be interested in a

follow-up spine course.


Acknowledgements

First, we would like to thank the excellent teaching faculty who gave so generously of their time. We

are very grateful to the AIC-CURE International Children’s Hospital for hosting this training, the

generous use of their venues and facilities and for organising the course dinner at Lake Navaisha.

Thank you to all who have supported the training and who have helped in its organisation and

running, including Peter Kyalo, Christine Kithome, Anne Sikiku, Titus Njoroge, John McLaughlin and

CURE International UK. This course was funded through the COOL Project (see Appendix 3) through

the Health Partnership Scheme, which is funded by the UK Department for International

Development.

Dr Joseph Theuri, Professor Chris Lavy & Grace Le

June 2014

Email: [email protected]

Web: www.ndorms.ox.ac.uk/cool.php


http://www.ndorms.ox.ac.uk/cool.php


APPENDIX 1: Comments from Participants

“I wish this kind of course can be organised in different COSECSA countries so that every orthopaedic surgeon

can attend. This is really good work done by COOL.”

“Thank you for the brilliant team of consultant spine surgeons and sharing your experience and expertise.”

“Thanks to COOL, CURE and others for organising the course which is needed for the region.”

“I would like to commend all the work COOL is doing. I have acquired a lot of knowledge through these courses

and recommend that you continue with this programme. Looking forward to future courses.”

“I have great praise for the COOL Project for organising several excellent training programmes over the past

months to enhance orthopaedic registrars and orthopaedic surgeons to interact across countries and attain

much more knowledge and skills to make our patients better in this regard.”

“The knowledge I gained here is of great importance- there are just a few individuals to teach us back home… I

urge you to keep it up.”

“Thank you very much for making all arrangements, it was a well organized course and indeed an interesting

one. I learnt new things and polished the things that I already knew. Also, it was a wonderful opportunity to

network and get acquainted with other surgeons from the COSECSA region.”

“Thanks a lot for your excellent organisation of the spine course. I was very happy & inspired by the course.

Hope it will continue to inspire fellow surgeons.”

“In general we enjoyed our stay at the Kijabe spine course - it meant a lot for us. We thank you for the great

opportunity you gave us. Keep it up with all the good work!!!”



APPENDIX 2: TEACHING TIMETABLE

Day 1 Wednesday 23 April

7.00 Breakfast

8.00 Devotions*

8.30 Welcome & Introductions Prof Lavy & Dr Theuri

8.45 Pre-course MCQ

9.00 Anatomy of the Spine Dr Muteti

10.15 Coffee

10.45 Imaging the Spine Dr Mandizvidza

11.30 Approaches to the Spine Mr Bowden

12.30 Lunch

13.30 Infections of the Spine, including TB Dr Maina

14.30 Degenerative Changes of the Lumbar Spine Prof Buteera

15.30 Tea

16.00 Degenerative Changes of the Cervical Spine Prof Marks

17.00 Questions and Close

17.10 End of Day

Day 2 Thursday 24th April

7.00 Breakfast

8.00 Devotions

8.15 Recap and Introduction

8.20 Cervical Spine Trauma Prof Buteera

9.10 Thoracic and Lumbar Spine Trauma Dr Mandizvidza

10.00 Coffee

10.30 Pedicle Screws All Faculty

12.20 Dr Parikh presentation

12.30 Lunch

13.30 Introduction to Deformity Mr Bowden

15.00 Tea

15.30 Operative Videos

16.00 Post-Course MCQ

16.15 Depart for course dinner


Day 3 Friday 25th April

7.00 Breakfast

8.00 Devotions

8.15 Recap and Introduction

8.20 Spine Surgery in Africa Prof Mkandawire

9.10 Case Discussions (1) All Faculty

10.00 Coffee

10.30 Case Discussions (2) All Faculty

11.30 Closing Session inc. Certificates & Course Evaluation

12.00 Lunch and Depart


APPENDIX 3:

COSECSA Oxford Orthopaedic Link (COOL)

COSECSA Oxford Orthopaedic Link (COOL) is a multi-country partnership programme between the

Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) at

the University of Oxford and the College of Surgeons of East Central and Southern Africa(COSECSA).

The three-year project (2012–2015) combines research and training in primary trauma care and

musculoskeletal impairment across the ten sub-Saharan countries in the COSECSA region: Burundi,

Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe. It aims to

meet the critical need for more health workers trained in treating serious injury and musculoskeletal

impairment. Primary activities include primary trauma care training courses in the COSECSA

countries, clinical fellowships in paediatric orthopaedics for surgical trainees, short orthopaedic

courses for surgical trainees, epidemiological research studies, and study grants for trainees to

undertake research in trauma and musculoskeletal impairment.

AIC-CURE International Children’s Hospital of Kenya

In 1998, CURE International, in cooperation with the African Inland Church, opened the AIC-CURE

International Children's Hospital in Kijabe, Kenya. The hospital provides medical and surgical care to

children with physical disabilities. The hospital provides the best medical and spiritual care possible

and expert medical training.

AIC-CURE International Children's Hospital was Africa's first orthopaedic/ paediatric teaching

hospital for children with disabilities. The 30-bed hospital provides care for children suffering from

conditions like clubfoot, cleft lip and cleft palate, curvature of the spine and disabilities stemming

from polio, cerebral palsy, muscular dystrophy and other congenital abnormalities.

Each year the hospital serves approximately 8,000 children and performs approximately 2,500

surgeries each year. The hospital also operates mobile clinics that travel to remote regions to

provide follow-up care and identify children who can be treated at the hospital.

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